头背侧入路腹腔镜解剖性左半肝切除术治疗肝癌的安全性及有效性

Safety and efficacy of laparoscopic anatomical left liver resection via cranial-dorsal approach for hepatocellular carcinoma

目的探讨头背侧入路腹腔镜解剖性左半肝切除术治疗肝细胞癌(肝癌)的安全性及有效性。方法回顾性分析2017年3月1日至2019年3月1日在中国人民解放军总医院第五医学中心行腹腔镜解剖性左半肝切除术的20例肝癌患者临床资料。其中男11例,女9例;平均年龄(53±7)岁。患者均签署知情同意书,符合医学伦理学规定。根据手术入路的不同分为常规组(10例)和头背侧入路组(10例)。头背侧入路组从头侧离断肝左静脉,同时从背侧打开Arantius韧带,全程显露肝中静脉主干,从头背侧向足侧离断肝实质,完成解剖性左半肝切除。比较两组围手术期、术后并发症发生率及术后生存率。两组手术时间等正态分布数据比较采用t检验,并发症发生率比较采用χ2检验。生存分析采用Kaplan-Meier法和Log-rank检验。结果头背侧入路组患者手术时间、术中出血量及术后住院时间分别为(97±19)min、(104±21)ml、(5.5±1.2)d,明显少于常规组的(139±24)min、(155±26)ml、(8.0±1.9)d(t=-9.837,-11.429,-7.362;P<0.05)。头背侧入路组患者术后第1天的ALT、AST、TB、WBC、CRP分别为(232±26)U/L、(267±33)U/L、(28±3)μmol/L、(8.3±1.1)×10^(9)/L、(54±16)mg/L,明显低于常规组的(302±31)U/L、(328±36)U/L、(34±5)μmol/L、(11.5±2.3)×10^(9)/L、(73±18)mg/L(t=-12.362,-14.151,-9.370、-7.633,-8.641;P<0.05);而ALB为(35.2±1.1)g/L,明显高于常规组的(32.9±1.5)g/L(t=8.016,P<0.05)。头背侧入路组患者术后并发症发生率为2/10,明显低于常规组的6/10(χ2=6.387,P<0.05)。头背侧入路组术后无复发生存率明显优于常规组(χ2=4.532,P<0.05)。结论头背侧入路腹腔镜解剖性左半肝切除术可全程循肝中静脉主干离断肝实质,实现真正意义上的解剖性左半肝切除,安全、有效,可提高患者术后无复发生存率。

Objective To evaluate the safety and efficacy of laparoscopic anatomical left liver resection via cranial-dorsal approach in the treatment of hepatocellular carcinoma(HCC).Methods Clinical data of 20 HCC patients who underwent laparoscopic anatomical left liver resection in the Fifth Medical Center of PLA General Hospital from March 1,2017 to March 1,2019 were retrospectively analyzed.Among them,11 patients were male and 9 female,aged(53±7)years on average.The informed consents of all patients were obtained and the local ethical committee approval was received.According to different surgical approaches,all patients were divided into the conventional group(n=10)and cranial-dorsal approach group(n=10).In the cranial-dorsal approach group,the left hepatic vein was severed from the cranial side,the Arantius ligament was incised from the dorsal side,the middle hepatic vein trunk was exposed throughout the procedure and the hepatic parenchyma was severed from the cranial-dorsal side to the foot side to complete the anatomical left liver resection.Perioperative condition,postoperative complications and survival rate were compared between two groups.The operation time and normal distribution data between two groups were compared by t test.The incidence of complications between two groups was statistically compared by Chi-square test.Survival analysis was conducted by Kaplan-Meier method and Log-rank test.Results The operation time,intraoperative blood loss and the length of postoperative hospital stay in the cranial-dorsal approach group were(97±19)min,(104±21)ml and(5.5±1.2)d,significantly less than(139±24)min,(155±26)ml and(8.0±1.9)d in the conventional group(t=-9.837,-11.429,-7.362;P<0.05).In the cranial-dorsal approach group,the levels of ALT,AST,TB,WBC and CRP at postoperative 1 d were(232±26)U/L,(267±33)U/L,(28±3)μmol/L,(8.3±1.1)×10^(9)/L and(54±16)mg/L,significantly lower compared with(302±31)U/L,(328±36)U/L,(34±5)μmol/L,(11.5±2.3)×10^(9)/L and(73±18)mg/L in the conventional group(t=-12.362,-14.151,-9.370,-7.633,-8.641;P<0.05).The ALB in the cranial-dorsal approach group was(35.2±1.1)g/L,significantly higher than(32.9±1.5)g/L in the conventional group(t=8.016,P<0.05).The incidence of postoperative complications in the cranial-dorsal approach group was 2/10,significantly lower than 6/10 in the conventional group(χ2=6.387,P<0.05).The recurrence-free survival rate in the cranial-dorsal approach group was significantly better than that in the conventional group(χ2=4.532,P<0.05).Conclusions Laparoscopic anatomical left liver resection via the cranial-dorsal approach can sever the liver parenchyma along the middle hepatic vein trunk throughout the whole procedure.It is a safe and efficacious anatomical left liver resection,which can enhance the postoperative recurrence-free survival rate.